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05/1812017 10:06 3083824033 TAX) P.0021003 <br /> • <br /> Application for Exemption FORM <br /> Neenrako oaponmant of <br /> REVENUE from Motor Vehicle Taxes by Qualifying Nonprofit Organizations A�� <br /> __ G •To be filed with your'county treater.. <br /> •Read instructions on reverse sIde. <br /> A plieant's Name Type of Ownership <br /> Good Samaritan Society Village Home Health Agency Z Nonprofit <br /> • <br /> Street or Other Mailing Address County Corporation <br /> 1043 S Locust St Hall ❑Other(specify): <br /> City State ' Zip Code state Where Incorporated <br /> Grand Island NE 68801 . NE <br /> IDENTIFY OFFICERS,DIRECTORS,OR PARTNERS OF THE NONPROFIT ORGANIZATION <br /> The Name.Address,City Stare.Zlp Code • <br /> Director Liza Nelson,1043 S Locust St,Grand Island,NE 68801 <br /> • <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> *Attach an additional sheet,N necessary. <br /> Registration bate or <br /> MotorVehicle Make Model Year Body Type Vehicle ID Number Date of Acquisition, <br /> II Newly Purchased <br /> Ford 2008 Focus 1PAHP35N58W267445 4/27/17 <br /> Exempt Uses of Motor VeniWe: Are the motor vehicles used exclusively <br /> ❑Agri0uttura1HortigAWral ❑Educations! ra Religious ®Charitable ❑Oenntery as indicated? <br /> Give detailed description of use.Wilding en explanation II multiple use Classifications exist ®YES 0 NO <br /> Vehicle will be used by the home health nurses and aides to drive to client's homes and <br /> If No.give percentage of exempt se <br /> provide in home nursing care. <br /> • <br /> Under penalties of law.I declare that I have examined this appaoation and that his,to the beat of my knowledge and bevel,true,complete,and comet.] <br /> also declare that I am duly atomized to sign sus exemption application.and that the organization owning the above•listedproperty does not discriminate <br /> M mem railipp or employment based oh race,color,or national origin. . l Min <br /> sign Q Uv L (20I`V`+"t Ariittt.�A - `Vt <br /> here ll Authorited Signature Tile Date <br /> FOR COUNTYTREASURER RECO—MMEENDATION <br /> 0/APPROVAL , <br /> PROVAL COMMENTS: " '/ PAIL AJcIS11 71 <br /> —A2A? <br /> ❑DISAPPROVAL // �f 7 <br /> Jk1k ,:�j / c Ji a Ial /csd/'/ <br /> 5g =,re el County Trend -r • Date <br /> FOR COUNTY BOARD OF EQUALIZATION USE ONLY <br /> • <br /> • <br /> .APPROVAL COMMENTS: <br /> • <br /> ❑DISAPPROVAL / l <br /> (o/d--/7 <br /> Authorized Signature '' Date <br /> Neoraake Depanmentot Revenue ANMdfad by Neb.Roy.Stat§$neorin Kr)and tdl.end eo. ia5.end 80-3,169 <br /> • <br /> ee-25a-200a Rev.8-2011 Supersedes 9&PZS2006 Rev.54009 <br /> PLEASE RETAIN A COPY FOR YOUR RECORDS <br />